Therapeutics Tutoring

Therapeutics Tutoring
Sarah Darby September 7, 2017

Ischemic Heart Disease
Ischemia = oxygen demand > oxygen supply Why might increased oxygen be demanded? Increased heart rate Increased blood pressure Increased contractions Why might decreased oxygen be supplied? Decreased coronary artery diameter (atherosclerosis!) Collateral blood flow Decreased blood pressure Decreased heart rate

Which of the following describes autoregulation? Epicardial vessesls dilate in response to critically narrowed arterioles. Epicardial vessels constrict in response to critically dilated arterioles. Arterioles dilate in response to critically narrowed epicardial vessels. Arterioles constrict in response to critically narrowed epicardial vessels.

Chronic stable angina Silent ischemia Prinzmetal’s Microvascular ACS Unstable angina NSTEMI STEMI

Prinzmetal’s Focal spasm NO increase in myocardial oxygen consumption Recurrent symptoms Prolonged acute, severe attacks Younger population (30-40s) Transient ST elevation on EKG

Prinzmetal’s Prophylaxis CCBs (both DHP and non-DHP) Acute Nitrates Do NOT use beta-blockers

Silent ischemia How do we know? EKG, ETT, after a PCI or MI Altered pain perception, autonomic neuropathy Look for different sx Dyspnea, palpitations, diaphoresis, n/v, weakness Make lifestyle changes! (stop smoking, exercise) Pharmacologic therapy: Aspirin 81mg daily Beta-blockers CCBs Long acting nitrates

Stable ischemic heart disease Quality Location Other Sx Duration Precipitating factor Relieving factor

Stable ischemic heart disease Typical Substernal CP w/ characteristic quality and duration Relieved by rest or NTG Caused by exertion or emotional stress Atypical: 2 Noncardiac: 0 or 1

Management of chronic stable angina BP goal of <140/90 Agents Beta-blockers ACE inhibitors Thiazides Possibly CCBs History of MI? Beta-blocker, ACEI, statin

Recommend optimal drug therapy for a patient with SIHD. Know which medications have mortality benefit! Mortality benefit ASA Beta-blockers ACEIs vaccinations Symptom relief CCBs Nitrates Ranolazine

Antiplatelets Aspirin Inhibits thromboxane formation Mortality benefit 325mg chew and swallow for acute attack 81mg daily for maintenance therapy (ALL patients unless CI) Clopidogrel Inhibits P2Y12 75mg daily Used when Aspirin is CI, possibly dual therapy for high risk Pts

TJ is a 64 yo 81kg female post-MI. PMH: HTN, T2DM, glaucoma, GI bleed (3 yrs ago). Meds: metformin, lisinopril, latanoprost. Allergies: ibuprofen (facial swelling), codeine (rash). Which antiplatelet therapy is appropriate for her? Aspirin 81mg daily Aspiring 325mg daily Clopidogrel 75mg daily Aspirin 81mg + Clopidogrel 75mg daily Ticagrelor 90mg daily

TJ is a 64 yo 81kg female post-MI. PMH: HTN, T2DM, glaucoma, GI bleed (3 yrs ago). Meds: metformin, lisinopril, latanoprost. Allergies: ibuprofen (facial swelling), codeine (rash). She is complaining of severe heartburn and asks for your recommendation. Which is not appropriate? Prilosec 20mg Protonix 40mg Dexilant 30mg Prevacid 15mg

Beta-Blockers Mortality benefit in post-MI and HF Decreases myocardial oxygen demand by… Decreasing HR Decreasing contractility Decreasing BP Do not use in Pts with... Severe bradycardia Severe hypotension High degree AV block Left ventricle failure Sick sinus syndrome

What side effects will you counsel a patient on who is picking up metoprolol tartrate for the first time? Exercise intolerance, tachycardia, warm extremities Fatigue, depression, exercise intolerance Insomnia, tachycardia, depression Warm extremities, insomnia, bradycardia

CCBs DHP = peripheral vasodilation Non-DHP = reduce contractility and HR Chosen second to beta-blockers Nitrates Converted to nitric oxide to induce smooth muscle relaxation Does NOT reduce mortality! Use nitrate free interval Sublingual is drug of choice for acute attack Preferred in Prinzmetal’s

Which of the following does not describe the effect of nitrates on myocardial oxygen demand and supply? Decrease preload Decrease peripheral resistance Dilation of epicardial coronary arteries Increase left ventricular volume

Which of the following is true regarding nitrate therapy? Nitrates provide a mortality benefit in patients with CAD Major side effects include headache, hypotension, and dizziness Isosorbide mononitrate undergoes extensive first pass metabolism Sublingual tablets should be used on a scheduled basis. Nitrates free intervals should be 1-2 hours

ACE inhibitors Blocks conversion of angiotensin 1 to 2, inhibits RAAS Mortality benefit Given to all patients who also have… HTN DM LVEF less than or equal to 40% CKD ARBS can also be used if patient does not like ACEI but are not as beneficial

JR is a 44 yo male who has struggled with HTN for the past few years. He takes Lisinopril 10mg daily. To help with his BP, he enjoys running around his neighborhood with his dog, Bone. Together they are training for a half marathon. Two months ago, JR woke up in the middle of the night with his heart racing and he couldn’t catch his breath. This happened again recently. What type of IHD does JR have? Silent Prinzmetal’s Chronic stable angina

JR is a 44 yo male who has struggled with HTN for the past few years. He takes Lisinopril 10mg daily. To help with his BP, he enjoys running around his neighborhood with his dog, Bone. Together they are training for a half marathon. Two months ago, JR woke up in the middle of the night with his heart racing and he couldn’t catch his breath. This happened again recently. What do you recommend for prophylaxis? SLG Nitroglycerin Amlodipine Metoprolol Increase his Lisinopril to 20mg daily APhA Complete Review for Pharmacy 11th Ed.

FR is a 57 yo male. BMI: 25. PMH: HTN, GERD, psoriasis. Social hx: 1/2PPD, social drinker. No active medications. His wife passed away a year ago, and he has stopped doing activities he once loved, like hiking and swimming at the Y every morning. His father experienced an MI at the age of 48. How many modifiable risk factors for atherosclerosis does FR have? 1 2 3 4 APhA Complete Review for Pharmacy 11th Ed.

SH is a 63 yo female who experienced a tightness in her chest located just beneath her sternum while she was pulling weeds in her front yard. She went inside to sit down, and the pain went away after 10 minutes. Classify her symptoms. Typical angina Atypical angina Noncardiac APhA Complete Review for Pharmacy 11th Ed.

DD is a 64 yo male who loves flying a kite with his grandchildren. One day he began experiencing a stabbing pain in his chest with every breath he took in. He became concerned and sat down on a bench to rest. The pain continued for over half an hour so he went to see his PCP. Classify his symptoms. Typical angina Atypical angina Noncardiac APhA Complete Review for Pharmacy 11th Ed.

CM is a 68 yo male who recently experienced a MI. His physician asks for your recommendation concerning initiation of treatment upon discharge. Which is most appropriate? Metoprolol 50mg BID Metoprolol 200mg BID Verapamil 180mg daily at bedtime Isosorbide mononitrate 60mg daily APhA Complete Review for Pharmacy 11th Ed.

Nitrates increase MVO2. True False BK is a 80 yo female. She comes to your pharmacy to pick up her Rx for Metoprolol. She tells you that she’s so thankful she hasn’t experience any chest pain for over a year now, but having a bottle of nitroglycerin in her bathroom at home keeps her at ease in case she does. What is your concern?? APhA Complete Review for Pharmacy 11th Ed.

ME is a 58 yo male in the emergency room for crushing chest pain relieved by sublingual nitroglycerin. HR is 58 bpm. BP is 130/85. Home meds include Sildenafil PRN. What do you recommend for initial outpatient therapy? Atenolol Verapamil Amlodipine Nitrates APhA Complete Review for Pharmacy 11th Ed.

What drug class is useful in hyperthyroidism? Beta blocker What drug class is favored in DM? Either type of CCB What drug class is favored in asthma and COPD? APhA Complete Review for Pharmacy 11th Ed.

Which of the following effects on myocardial oxygen demand is NOT affected by beta-blockers? Decreased HR Decreased BP Decreased contractility Peripheral vasodilation Decreased conduction through AV node APhA Complete Review for Pharmacy 11th Ed.

64 yo male with SIHD complains of angina that occurs after walking 2-3 blocks. No lesions detected on his coronary angiogram (cardiac cath) are amenable to intervention (stent of CABG). HR is bpm. BP is 130/68. Current Rx Aspirin 81mg daily Rosuvastatin 40mg HS Metoprolol 50mg BID Ramipril 10mg daily Tadalafil PRN Which of the following will most benefit his angina? Add isosorbide mononitrate 60mg daily Add Diltiazem 180mg daily Increase Metoprolol to 100mg BID Add Amlodipine 5mg daily APhA Complete Review for Pharmacy 11th Ed.

Ranolazine Indicated for chronic angina Works by inhibiting late inward sodium channel, which leads to decreased calcium influx = reduced ventricular tension and oxygen consumption No hemodynamic changes MARISA Improved time to angina onset and total exercise duration as compared to placebo CARISA Improved angina when used in combination with other therapies TERISA Similar improvements in angina in patients with diabetes MERLIN-TIMI 36 No difference in terms of CV death or MI compared to placebo Decreased rate of ischemia compared to placebo

Ranolazine Dose: 500mg BID up to 1000mg BID Concern for prolonged QT interval No torsades de pointes occurred during clinical trials Contraindications Pre-existing QT prolongation Simultaneous QT-prolonging drug use Strong CYP 3A4 inhibitors or inducers Significant hepatic impairment Drug Interactions! Weak inhibitor of 3A4 Moderate inhibitor of 2D6 and Pgp Substrate of 3A4 (also 2D6 and Pgp)

Which of the following will increase plasma concentrations of Ranolazine? Rifampin Ketoconazole Phenytoin Metoprolol

Which of the following will decrease plasma concentrations of Ranolazine? Ritonavir Diltiazem Lisinopril Carbamazepine

Which of the following should not be used in combination with Ranolazine? Amiodarone Simvastatin Verapamil Gentamicin

Which of the following does NOT have a contraindication with Ranolazine? SSRIs Methadone Carvedilol Haloperidol

Which of the following effects is associated with use of ranolazine? Decreased myocardial contractility Decreased arterial pressure No change in heart rate Increase in coronary blood flow

Therapeutics Tutoring Questions?
Sarah Darby September 7, 2017

Therapeutics Tutoring

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